Healthcare Provider Details

I. General information

NPI: 1780009357
Provider Name (Legal Business Name): AMAZING GRACE COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2014
Last Update Date: 02/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6001 LAKESIDE AVE STE 30
RICHMOND VA
23228-5749
US

IV. Provider business mailing address

6361 SPRINGCREST LN
RICHMOND VA
23231-5326
US

V. Phone/Fax

Practice location:
  • Phone: 804-269-3837
  • Fax:
Mailing address:
  • Phone: 804-269-3878
  • Fax: 804-269-3885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number1896-03-001
License Number StateVA

VIII. Authorized Official

Name: MRS. YVONNE NWINEMU NDIFOR-MCNEIL
Title or Position: PROGRAM DIRECTOR
Credential: BA
Phone: 804-687-2097